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BMJ 2011;343:d5184 doi: 10.1136/bmj.d5184
OBSERVATIONSIs your mum on drugs?
When “de-prescribing” may be the best medicine
Ray Moynihan author, journalist, and conjoint lecturer, University of Newcastle, Australia
Soon after she went into a small hospital a few years back,
In this case, though, hearing what happened to Fervid Trimble
Johanna Trimble’s mother in law seemed to enter a rapid
helps tell the wider story of the dangerous overdrugging of our
elders and the fact that families and loved ones can do something
Fervid Trimble was at the time a woman in her late 80s, living
independently in a senior citizens’ home near Seattle in the
The first thing Fervid’s family did was to tell the doctors that
United States. After a bout of diarrhoea and dizziness she was
she was not to be given any new drugs without the family’s
admitted to the healthcare centre close to the home, but her
permission, and they’ve since released a short set of tips urging
family was soon shocked by the quick deterioration in her health
people to listen closely to their older loved ones, compare any
and the emergence of some strange new symptoms, including
new “symptoms” with drug side effects, and seek out
delusions. “She wasn’t able to wake up, and we couldn’t wake
her,” says Johanna. “It didn’t seem like normal sleep.”
For Johanna Trimble the experience was life changing. “I was
After discussions with the centre’s staff the family discovered
looking at all the other people in long term care facilities, where
that Fervid was taking several new drugs, including a painkiller
family members were either unaware of the problems or didn’t
and an antidepressant. “They said she was depressed,” says
want to rock the boat, and I thought, ‘Who the hell is going to
Johanna, “but we believed that she was rightly grieving for the
speak up for these people?’” she told the BMJ. She has since
loss of her former life, because she was now stuck inside a
become a patients’ advocate, working with public agencies and
hospital room. It made sense to us that she was sad.”
communities in Canada where she lives, promoting the idea that
At the same time a psychiatrist diagnosed “Alzheimer’s” and
discontinuing drugs can sometimes be the best prescription. “I
suggested that the 88 year old take donepezil (Aricept), which
really wanted to do something about this epidemic of
the family declined after learning that there was little evidence
that the drug offered clinically meaningful benefits.
Last year the Archives of Internal Medicine published a
After further research the family members began to suspect that
feasibility study of drug discontinuation among elderly people
their mother was overmedicated and experiencing the harmful
in Israel,3 with extraordinary findings. Using an established tool,
effects of a drug interaction, rather than depression or
researchers were able to cut the average number of medications
Alzheimer’s disease. In consultation with health centre staff
in half, from roughly eight to fewer than four per person. Just
they opted for a partial “drug holiday,” winding back some of
2% of discontinued drugs were restarted; no adverse effects of
discontinuation were reported; and almost 90% of people
“She recovered completely,” Johanna told the BMJ last month.
“Not only cognitively, but she was also soon doing exercises
The study was co-run by Dee Mangin, an academic at
again. She really came right back.” The family members have
Christchurch School of Medicine in New Zealand and a general
compelling before and after photos to back up their views, which
practitioner who is well schooled in evidence about the harms
are part of a presentation that Johanna now regularly delivers,
of unnecessary care. “I look as hard at stopping medications for
my patients as I do at starting them,” she says.
As a journalist who’s been writing about evidence for many
Dr Mangin has written previously in the BMJ about the way
years, I’m acutely aware of the benefits and risks of the powerful
that quality measures can drive up prescriptions of questionable
anecdote. Used inappropriately, anecdotes can and do distort
benefit and why the current approach to “preventive care” for
understanding and mislead readers—a daily reality of the hype
elderly people requires a rethink.4 “Improving the art of ‘not
based reporting in tabloids and on screens around the world.
doing’ is what will determine quality care in the next few
decades,” argues Dr Mangin, who is part of an informal global
For personal use only: See rights and repr
BMJ 2011;343:d5184 doi: 10.1136/bmj.d5184
network hoping to run a randomised controlled trial of
drug holiday for their elderly patients might be something to
For Johanna Trimble, reducing numbers of unnecessary drugs
and the associated delirium didn’t just improve her mother in
Trimble J. Is your mom on drugs? Find out what to do about it.
law’s health; a returned lucidity in the following years of her
Trimble J. Is your mom on drugs? Ours was—and what we did about it.
life also enabled Fervid to pass on the precious wisdom of those
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of
multiple medications in older adults: addressing polypharmacy. Arch Intern Med
“Before she died, she spoke to all of us, touching and inspiring
Mangin D, Sweeney K, Heath I. Preventive health care in elderly people needs rethinking.
us, pouring out all her wisdom and love,” says Trimble. “Many
families are not having these powerful experiences because their
elders are too drugged.” Perhaps as northern hemisphere health
professionals return from well earned holidays, the idea of a
For personal use only: See rights and repr

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